What Should We Do About Undertreatment of Late Life Psychiatric Disorders in Primary Care?

The paper “Psychiatric Diagnosis and Intervention in Older and Younger Patients in a Primary Care Clinic: Effect of a Screening and Diagnostic Instrument,” by Valenstein, Kales, and co-workers,1 reports findings in regard to the use of a standardized approach to screening for psychiatric symptoms and diagnosing mental disorders in a Veterans Administration primary care clinic. The screening instrument, the PRIME-MD,2 was designed specifically to probe for mood-, anxiety-, somatoform-, eating-, and alcohol-related disorders in primary care settings. The findings were that older patients were less likely to screen positive for symptoms suggesting a psychiatric disorder, less likely to be diagnosed, and less likely to receive treatment. The figures for positive screens, diagnoses, and treatments were 85.4%, 26.0%, and 15.8% in younger adults versus 78.6%, 13.0%, and 6.8% in geriatric patients. Although these findings might suggest that mental disorders are less of a problem in late life, further analyses tell a different story. The decrease in psychiatric diagnoses in older people remains significant in analyses that control for the lower rates of positive screens in older patients. Similarly, the decreased rate of interventions in the aged remains significant in analyses that control for the lower rates of diagnoses. Thus, this paper suggests that psychiatric disorders are underdiagnosed and undertreated in older primary care patients and that this problem persists even after use of a standardized approach for case identification. As always, it is possible to raise questions about the paper. One concern must be about the value of a screening instrument on which 85.4% of the young adults and 78.6% of older patients screen positive. Another must be about the way in which ignoring cognitive impairment and the diagnosis of Alzheimer's disease and related disorders could have affected the findings. Moreover, the strength of this paper includes its consideration of a wide range of psychiatric disorders, but it is unfortunate that it did not present findings according to diagnosis. Nevertheless, the conclusion that there is less diagnosis and treatment of a spectrum of psychiatric disorders in primary care as patients age must be recognized as a significant contribution to the geriatric literature. The findings about mental health treatment in primary care are important because there is a growing literature demonstrating that older patients are less likely to seek out treatment from mental health specialty providers or to follow through when their physicians make referrals.3 Thus, primary care physicians are, in fact, the major professional providers of mental health care for older people. However, as indicated in this paper and elsewhere, this de facto system for mental health care falls down specifically with older individuals. There are two possible explanations for the problems of delivering mental health care to older primary care patients. One is that the evidence available to guide clinical decision-making does not adequately address the problems of primary care patients, and psychiatric disorders are undertreated because the treatments that have been developed for those patients seen in mental health care settings are not applicable to those seen in primary care. The other possibility is that undertreatment reflects a series of interacting barriers that make it difficult for primary care providers to apply available knowledge to deliver effective treatment.4,5 These include the stigma associated with mental illness, the discriminatory biases against reimbursement for mental health care, providers'limited knowledge about mental disorders, the time required to assess adequately symptoms and signs manifest through behavior and subjective experience, and the nature of disorders that require weeks or months for acute interventions and even longer periods of time for the continuation and maintenance treatments that are necessary more often than not. Both sets of concerns may be valid. There is clearly a need for more knowledge about the symptomatology and the efficacy of treatments specifically for the mental disorders observed in older patients in primary care. However, there is also evidence that practice-level interventions designed to overcome the barriers to delivery of current treatments can improve outcomes. see also p 1499 Among the disorders in question, depression is the most prevalent and the best investigated. The growing literature on the diagnosis and treatment of major depression in late life demonstrates that current approaches to pharmacotherapy are as effective in older as in younger adults.6 Although the research supporting the use of psychotherapy in late life is less well developed, available findings demonstrate the value of interpersonal, cognitive-behavioral, brief dynamic, and problem-solving therapies.7 There have been questions about whether standard treatments are applicable to major depression as it most often occurs in late life, i.e., in the context of disabling medical or neurological illnesses. However, findings from placebo-controlled, randomized clinical trials demonstrate that antidepressant therapy for major depression remains efficacious in the presence of illnesses as diverse as Alzheimer's disease, stroke, Parkinsonism, diabetes, ischemic heart disease, cancer, and chronic obstructive pulmonary disease, as well as in the presence of the multiple disabling conditions seen in long-term care settings.8–10 Because epidemiological evidence demonstrates that late life depressions are less likely to meet diagnostic criteria for major depression than those seen in younger adults,11 there have been questions about whether treatments developed and validated for major depression remain safe, effective, and necessary for the wider spectrum of milder depressions. One recent study has reported that a psychosocial intervention leads to better outcomes than usual care for older medical patients with minor depression,12 and others report positive findings from mixed samples of those with major and other depressions. However, findings from mixed age patients suggest that individuals with minor depression respond so readily to placebo or low levels of usual treatment that it is difficult to demonstrate positive outcomes from specific treatments.13,14 Thus, definitive answers about when and how to treat patients with those depressions that are most common in primary care must await further research. The research literature is less well developed for the other mental disorders of late life, and further information is needed to guide practice. Current state of the art thinking regarding the diagnosis and treatment of alcohol-related disorders was summarized in a recent treatment improvement protocol.15 The areas of anxiety disorders and other conditions remain relatively underdeveloped. The available literature on practice-level interventions designed to overcome barriers to the provision of mental health services has also focused primarily on depression. Research evaluating the impact of screening, consumer education, provider education, treatment algorithms, practice guidelines, and varying approaches to cueing practitioners has produced short-term effects on outcomes that are mixed, at best, and lasting effects that are quite limited. One model that has proved successful in improving outcomes for mixed age patients with major depression has been to import mental health professionals into general medical practices and have them collaborate with primary physicians in providing care.16 Another has been to import pharmaco- and psychotherapists trained specifically to deliver care according to AHCPR major depression guidelines.17 Current research in a number of centers is evaluating the extent to which these positive findings can be maintained, and the barriers to treatment of depression overcome, when screening, diagnosis, treatment planning, and the conduct of treatment is facilitated by augmenting the primary care practices with nurses trained specifically as depression specialists who function as care managers. One highly informative negative finding comes from a study that evaluated the effects of a primary care intervention that provided physicians with screening results, diagnostic assessments, and individualized treatment recommendations for their patients.18 Relative to usual care, this package did lead physicians to start treatment more frequently, but it did not lead to more positive clinical outcomes. Thus, facilitating diagnosis and the initiation of treatment are necessary, but not sufficient, to overcome the barriers to care. In addition, it is necessary to target treatment adherence and monitor outcomes, modifying first line treatments when needed. For those concerned with improving the public health of older populations, it should be clear that further research is necessary to establish the effectiveness of treatments for the mental disorders of late life and to establish methods for delivering these interventions in real life settings. The issues that must be addressed cross between the traditional domains of clinical and health services research. Although there is a need for further randomized clinical trials on the outcomes from well defined treatments, it will be necessary to conduct these studies with representative patients rather than the highly selected individuals who meet the rigorous inclusion/exclusion criteria for most current studies. There is a need for further research on practice level interventions designed to develop systems that make effective care more available, but these must attend to the heterogeneity of the mental disorders of late life and patient-level predictors of poor outcomes to a much greater extent than current approaches to services research. Thus, improving the care of older patients in primary care settings will require investigations of a hybrid nature that combine elements of both clinical and services research. For individual physicians responsible for the care of their own patients, findings about the undertreatment of mental disorders in geriatric patients represent warnings and challenges that should raise consciousness about the need to identify psychiatric disorders, to institute appropriate treatments, and to monitor outcomes and modify first line treatments for those who do not respond adequately. Ira R. Katz, MD, PhD University of Pennsylvania Philadelphia, PA STATEMENT OF OWNERSHIP MANAGEMENT AND CIRCULATION (Required by 39 U.S.C. 3685) . Publication Title: JOURNAL OF THE AMERICAN GERIATRICS SOCIETY; 2. Publication no.: 0002-8614 . Filing Date: 10-01-98; 4. Issue Frequency: monthly; 5. No. of issues published annually: 12; 6. Annual subscription price: $147.00. 7. Complete mailing address of known office of publication: 351 West Camden Street, Baltimore, MD 21201-2436. 8. 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